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Tuesday, July 29, 2014

Would We Be Ready?

"The employee said the pilot then simultaneously brought the helicopter up off the pad and forward. He described the takeoff as "kind of shaky." He said that on other flights, pilots will normally bring the helicopter into a hover, do an instrument check, and then start forward flight. However, in the three times he had flown with the accident pilot, he always took off without hovering."

This is an account of an engine failure in a Bell 206, in the Gulf Of Mexico. While it does not involve EMS, it DOES involve a helicopter many of us work in. There are lessons to be learned here...

CEN14FA004

"The following is an INTERIM FACTUAL SUMMARY of this accident investigation.
A final report that includes all pertinent facts, conditions, and circumstances
of the accident will be issued upon completion, along with the Safety Board's
analysis and probable cause of the
accident:"

On October 9, 2013, about 0720 central daylight time, a Bell
206L-3, N54LP, was substantially damaged when it impacted water shortly after
takeoff from the Main Pass 107D oil platform in the Gulf of Mexico. The
commercial pilot was fatally injured and the three passengers were seriously
injured. The helicopter was registered to and operated by Panther Helicopters,
Inc., Belle Chasse, Louisiana. A company visual flight rules flight plan was
filed for the flight that was destined for the Belle Chasse Heliport (06LA),
Belle Chasse, Louisiana. Visual meteorological conditions prevailed for the
business flight that was conducted under the provisions of 14 Code of Federal
Regulations Part 135.

The purpose of the flight was a routine crew change
at the MP107D oil platform. The pilot and three oil platform employees departed
06LA about 0633 and flew direct to the platform. The crew change consisted of
dropping the three platform employees off, picking up three other employees,
then returning to 06LA. After landing on the platform, the pilot did not shut
down the helicopter down and stayed at the controls with the main rotor turning
until the crew change was complete.

A witness was standing on the MP108E
oil platform, which was about 300-400 yards from MP107D. He had a clear and
unobstructed view of the MP107D platform and saw the helicopter sitting on the
helipad with its main rotor blades turning. The helicopter was facing
east-northeast. The witness said that he saw three people get off the helicopter
and then three other people get on the helicopter. He described the weather as
"stale" and the wind sock was "limp."

About 1 to 2 minutes later, the
witness observed the helicopter pull up into a 3 to 4-foot-high hover over the
helipad and make a slight bearing change toward the east. He said at that point,
everything was completely normal with the helicopter. The helicopter then moved
forward and started to take off toward the east. The witness said as soon as the
helicopter cleared the helipad's skirting, he saw a flash and a large
(10-foot-high x 10-foot-wide) "poof" or "cloud" of white smoke come from
directly under the main rotor blades near the exhaust section of the helicopter.
This was followed by a loud, high-pitched, screeching noise, as if the engine
were being revved up. The witness said this "poof" of smoke occurred when the
helicopter was parallel to a flare boom that extended directly out from the
platform and was positioned on the north side of the helipad. The witness said
that after he saw the "poof" of smoke, the helicopter nosed over toward the
water. The helicopter cleared the helipad's skirting and did not strike the
flare boom as it descended.

The witness said he saw the helicopter's
emergency floats fully expand before it impacted the water. The helicopter hit
the water hard with the main rotors still turning; became completely submerged
and rolled inverted. The wintess could see the helicopter's skids near the
surface of the water and noted that one emergency float (he could not recall
which one) had completely separated from the helicopter.

The witness did
not see anyone coming to the surface and used his VHF handheld radio to issue a
"may-day-call." He also directed a field boat, which was at the base of the
MP108E platform, to the helicopter. He said that by the time the boat arrived,
two deck hands were already stripped down and jumped into the jellyfish infested
water to help the occupants of the helicopter. Although one of the deckhands had
an allergic reaction to the jellyfish stings, they were able to get three of the
four occupants out of the helicopter and onto the field boat. The pilot's feet
were "caught up in the controls" and it took about 15 minutes for them to get
him freed.

The witness said he did not see any methane gas being vented
from the flare boom on the morning of the accident; however, he did see a large
(size of an automobile) "methane cloud" coming from the flare boom the day
before the accident between 12 and 5 pm. The methane cloud was located right
where he saw the poof of white smoke on the day of the accident. The witness
said he has seen methane being vented from the MP107D flare boom on several
occasions. He said they vent "a lot of gas" several times a week.

In a
telephone conversation, a platform employee, who was a passenger on the
helicopter, stated that he had just completed a 14-day "hitch" on the MP107D oil
platform and was headed back to Louisiana. On the morning of the accident, he
and the two other platform employees prepared the platform for a crew change and
waited for the helicopter to arrive. The employee said that after the pilot
landed, he briefly talked to one of the on coming employees about a hunting
trip. He then loaded his bags and was the last one to board the helicopter. The
employee said he got in the helicopter via the left rear door and sat in the
left seat, facing forward. The passenger then donned an inflatable life vest,
put on a headset, and fastened his seatbelt. He tugged on the seatbelt to make
sure it was secure and snug.

The employee said that once everyone was
fastened in, they gave the pilot a "thumbs-up" and the pilot prepared to depart.
At this point, everything regarding the flight was "normal."

The
employee said the pilot lifted the helicopter up off the platform and began
forward flight. When the helicopter was over the water, he heard a loud noise
overhead as if the transmission was coming a part. The other passenger that was
seated next to him asked, "What's that?" The employee told him to "hold on," and
the next thing he knew they hit the water with a "big splash." Prior to impact,
he did not hear any alarms going off in the cockpit and did not remember the
emergency floats expanding. The pilot did not say anything during the accident
sequence.

The employee stated that he may have passed out for a few
minutes. When he regained consciousness, he realized he was out of his seatbelt
(he did not recall unfastening the buckle). The helicopter had rolled on-to its
left side, and he was trying to find the door. When he tried to stand up, he
realized he couldn't feel his legs. At this point, the passenger, who had been
seated next to him had opened the right door and was climbing out. Although
water was entering the cabin, he and the passenger in the front left seat were
able to keep their heads above water. There was no movement or response from the
pilot.

The passenger said that he sat there for a few minutes, and when
the helicopter began to roll inverted, he was able to push himself out of the
right rear door where the other rear seat passenger had been sitting. He then
tried to inflate his life vest, but when he pulled on the inflation-lanyard it
would not inflate. He said that he was not familiar with this particular model
vest and he did not try to self-inflate the vest. Shortly after, the front seat
passenger was able to get out of the helicopter. The two rescuers who dove in
the water from the life boat were trying to get the pilot out, but his seatbelt
was "too tight," and his foot was stuck in the windshield.

The employee
said that while the pilot was being extracted, the other rear seat passenger was
dragged to the life boat via a life ring. At this time, the employee saw a life
vest floating in the water. He was able to inflate it and used it to support
himself until he was rescued. The employee said he was in a "panic state of
mind" and didn't recall getting onto the boat.

In a telephone
conversation, another platform employee, who was also a passenger on the
accident flight, stated that he had just completed a 14-day "hitch" on the
MP107D oil platform. He said that on the morning of the accident, he and the two
other employees prepared the platform to be turned over to the on-coming crew.
While eating breakfast, he heard the pilot make a radio call that he was 10
minutes out with three onboard. The employee said the platform's lead operator
responded to the pilot, and told him he had a "green deck" to land. The employee
then grabbed his bags and headed up to the helipad. After the helicopter landed,
the three on-coming crew members got off the helicopter and retrieved their bags
from the cargo bay. The employee said he placed his bags in the cargo bay and
walked around the front of the helicopter. The pilot gave him a "thumbs-up" and
a smile, and then the employee got in the helicopter. He sat in the rear of the
helicopter on the right side, facing forward. He donned the provided inflatable
life vest, a headset, and fastened his seatbelt assembly. The employee said
another employee sat next to him on the left side, forward facing seat and the
other sat in the front left seat.

The employee said he did not talk to
the pilot or notice anything unusual about his behavior. After the crew was
onboard, the pilot asked if they were ready to go and they responded they were
ready. The employee said the pilot then simultaneously brought the helicopter up
off the pad and forward. He described the takeoff as "kind of shaky." He said
that on other flights, pilots will normally bring the helicopter into a hover,
do an instrument check, and then start forward flight. However, in the three
times he had flown with the accident pilot, he always took off without
hovering.

The employee said that once the helicopter moved off the
helipad and over the water, there was a "winding noise" then a "pop" sound. His
first instinct was that there was a problem with the transmission. He did not
hear alarms going off in the cockpit or see any annunciator lights. The
helicopter then nosed over at an angle toward the water. The employee said that
as the helicopter descended, the emergency floats expanded just before they hit
the water. He described the impact as a "big ole crash like landing on
concrete." The employee said that he then heard moans of pain coming from the
other men onboard and that water started to enter the cabin. The helicopter had
rolled on to its left side. He then undid his seatbelt and opened the right
cabin door. The employee said he turned left and asked the passenger next to him
if he was okay, and he responded that he could not feel his legs. The employee
said the passenger had come completely out of his seatbelt during the impact.

The employee exited the helicopter and held onto the skid of the
helicopter because when he pulled on his life vest inflation-lanyard, it did not
expand. He said the rear seat passenger's life vest also wouldn't inflate but
the passenger's vest on the front seat did inflate. He was not sure about the
pilot's life vest.

The employee said he saw the lift boat and told the
rescuers there were three more people on board. He was able to get onto the life
boat, where he laid down until help arrived.

The employee reiterated
several times there was nothing mechanically wrong with the helicopter until
they started to takeoff. He said the platform was not venting methane that
morning and the wind was calm.

In a telephone conversation, one of the
platform employees, who had just been dropped off at the platform, stated that
he and the two other platform employees arrived at Panther Helicopter's facility
in Belle Chasse, Louisiana, on the morning of the accident around 0600. He said
all three of them signed in and waited for the helicopter to be ready. When they
were ready to board, he got in the front left seat, put on his life vest and
fastened his seatbelt. The pilot made sure everyone was wearing their life vests
and seatbelts before they departed. While en route, the employee said he briefly
spoke to the pilot and he did not notice anything unusual with his demeanor. He
said the helicopter was operating fine and there were no indications of any
problems.

The employee said that after a normal landing, he exited the
helicopter, retrieved his bags from the cargo bay, and went downstairs into the
platform housing. There he had a quick changeover briefing with the
departing-lead. Several minutes later, he heard the helicopter's engine spool up
as it prepared to takeoff. Everything sounded normal until he heard a "pop" and
a high-pitched whine followed by a low pitch whine as if the engine were
spooling down. He described the noise as a turbine or compressor winding down.
At that point, the employee knew something was wrong and ran outside. Once
outside, he saw the helicopter in the water on its right side and one passenger
was exiting the helicopter. The employee said he went back inside and called the
Coast Guard, Panther Helicopters, and his senior management.

According to
the operator, the helicopter was equipped with a SkyConnect tracking system. The
last registered altitude of the helicopter was about 141 feet.

PILOT
INFORMATION

The pilot held a private pilot certificate for airplane
single-engine land and a commercial pilot certificate for rotorcraft-helicopter.
His last Federal Aviation Administration (FAA) second class medical was issued
on January 10, 2013. According to the operator, the pilot had accrued a total of
3,450 total hours; of which 3,423 hours were in helicopters, and 177 hours were
in the same make/model as the accident helicopter.

The pilot was hired by
Panther on June 17, 2013. His training was conducted by Panther in the Bell 206
helicopter. The pilot successfully completed his CFR Part 135.293 and 135.299
FAA check ride on July 25, 2013.

AIRCRAFT INFORMATION

N54LP was a
1991 Bell 206L-3 helicopter with serial number 51466. The single-engine
helicopter was powered by an Allison M250-C30P turbo-shaft engine with serial
number CAE 895524, which drove a two-bladed main rotor system and a two-bladed
tail rotor. The helicopter was configured to carry one pilot and six passengers.

According to the operator, the helicopter was maintained in accordance
with the manufacturer's continuous inspection program. The helicopter's last
inspection (event 2) was completed on October 3, 2013. The helicopter's total
time at the time of the accident was 11,238 hours.

METEOROLOGICAL
INFORMATION

At 0600, weather conditions at the Belle Chasse heliport,
Belle Chasse, Louisiana, about 72 nautical miles northwest of the accident site
were calm wind, visibility 10 miles and clear skies, with a temperature of 65
degrees Fahrenheit.

At 0655, weather conditions at the New Orleans Naval
Air Station (NBG), Louisiana, about 72 miles northwest of the accident site were
calm winds, visibility 10 statute miles with shallow fog, few clouds at 5,000
feet, temperature 57 degrees F, dew point 60 degrees F, and altimeter 30.06
inches of Mercury.

AIRPORT INFORMATION

According to the Bureau of
Safety and Environmental Enforcement, the Gulf of Mexico is divided into three
primary subdivisions: Western Gulf of Mexico, Central Gulf of Mexico, and
Eastern Gulf of Mexico. The three subdivisions are further divided into areas
and blocks. The blocks are about 3 miles long and 3 miles wide and are used for
oil/gas lease identification. There are over 2,600 offshore production platforms
in the Gulf of Mexico region.

MP107D is an offshore oil production
platform, (29 degrees 30 minutes north latitude and 88 degrees 42 minutes west
longitude). MP107D is about 37 nautical miles northeast of Venice, Louisiana.
MP107D features a single helideck (about 35-feet-long and 35-feet-wide).

WRECKAGE INFORMATION

The wreckage was recovered and moved to
Panther's maintenance facility in Belle Chasse, Louisiana. The National
Transportation Safety Board (NTSB) Investigator-in-Charge conducted an
examination of the airframe and a visual examination of the engine on October
14, 2013. Also present for the examination were representatives of Panther,
Rolls Royce, and Bell Helicopter.

The helicopter was secured and upright
on a flatbed trailer. The engine, transmission, and main rotor system remained
attached to the airframe. One of the main rotor blades had been cut off for
transport and the other blade was fractured during the impact with the water.
The section of fractured blade was never located. The tail boom had separated
from the fuselage about 12-inches aft of the tail boom attachment point. The
tail rotor assembly had separated aft of the elevator and was never recovered.

The entire windshield on the right side of the helicopter was missing,
and a large section of windshield was missing on the left side. The forward and
aft passenger doors were removed. The aft cargo bay was crushed upward from the
bottom of the fuselage. Salt water corrosion was noted throughout the fuselage
and engine.

Flight control continuity was confirmed for the cyclic and
the collective to the main rotor system. Partial flight control continuity was
established for the anti-torque pedals from the cockpit to the point where the
tail boom had separated from the fuselage.

The throttle was locked in
the fuel-cutoff position, which was consistent with the setting on the fuel
control unit.

Examination of the pilot's 4-point shoulder
harness/seatbelt assembly revealed that it was secure at all fuselage attach
points. The inertial reel was locked, and stretch marks on the belt material
were observed in several locations. The latching mechanism functioned normally
when manually tested.

The front seat passenger's 4-point shoulder
harness/seatbelt assembly was also secure at all fuselage attach points and
functioned normally when manually tested. The inertial reel was not
locked.

The metal seatbox for the front passenger's seats was crushed
downward.

All of the rear seat shoulder harness/seatbelt assemblies were
secured at their respective fuselage attachment points and the latching
mechanisms functioned normally when manually tested.

A visual examination
of the engine revealed that it did not sustain much impact damage; however,
several large holes were observed in the exhaust collector support stack. A hole
was also observed in the cowling on the right side near the area of the support
stack. Oil was in the bottom of the engine pan and the forward engine mounts
were slightly bent. All engine fuel, oil and pneumatic lines, and b-nut fittings
were tight and no leaks were observed.

The engine was removed and shipped
to Rolls Royce, where a tear down examination was conducted on November 6-7,
2013, under the supervision of an NTSB investigator. Representatives of the FAA,
Rolls Royce, Panther and Bell Helicopter were also present for the
exam.

The centrifugal compressor section was disassembled. The #1 and #2
bearings were examined and found to be free of any indications of distress. The
compressor impellor vanes exhibited slight indications of rotational rubbing;
however, no other indications of ingestion or other damage were
noted.

The gearbox was disassembled. Examination of internal components
did not reveal any obvious defects to gearing. The gearbox interior contained a
large quantity of the magnesium gearbox case, corrosion deposits and material
from the effects of sea water immersion and recovery operations.

The gas
generator turbine and power turbine sections were disassembled. The Stage 1
turbine section was undamaged. The Stage 2 section revealed damage to the
turbine disk blades, with one blade liberated from the blade root. All of the
Stage 3 turbine disk blades were liberated at the blade roots. All of the Stage
4 turbine disk blades were damaged, with about 320 degrees of the blade shrouds
detached. The blades did not breach the turbine cases.

The turbine
section stages were retained and are currently undergoing metallurgical
examination.

MEDICAL AND PATHOLOGICAL INFORMATION

Toxicological
testing was conducted by the FAA Toxicology and Accident Research Laboratory,
Oklahoma City, Oklahoma. The pilot tested positive for Cetirizine in his blood
and urine. Diphenhydramine was detected in his urine and blood (.024ug/ml,
ug/g). In addition, Ibuprofen was detected in the pilot's urine.

Editor's note: During annual recurrent ground school recently, the instructor mentioned that pushing forward on the cyclic immediately following an engine failure out-of-ground-effect will result in loss of rotor rpm. The urge to push forward must be resisted until the rotor system completes it's transition from normal thrusting state (air being driven down through the rotor system) to autorotational state, (air passing up through the rotor system and driving the rotor). The indication that this transition is complete is an increase in rotor rpm...

1 comment:

It’s very Informative Thanks for sharing With Us. Good job keep it upUrban Aero Systems as an Aviation Infrastructure company that aims to introduce cutting-edge aerospace support technologies into India and provides Helipads in India and Heliports in Bangalore

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About Me

I am a retired army aviator, and flew EMS helicopters from 1999 until 2015. I have flown at many different programs under traditional, community based, and hybrid models. I enjoy interacting with crewmembers as we together learn how to avoid becoming a statistic and the topic of someone else's safety brief. I teach Air Medical Resource Management, and am a member of the National EMS Pilot's Association's board of directors.